A 62-year-old man comes to the emergency department for evaluation of weakness. Five hours ago, he experienced abrupt-onset weakness in his left arm and leg. The symptoms improved over the next 30 minutes and he had no associated blurry vision, slurred speech, or facial drooping. However, the patient states he is still not "back to normal." He has never experienced similar symptoms. Medical history is significant for hypertension, hyperlipidemia, and osteoarthritis. The patient takes no medications. He has a 25-pack-year history but quit smoking 5 years ago. Blood pressure is 160/96 mm Hg and pulse is 69/min and regular. There are no carotid bruits. Neurologic examination shows mild, left-sided pronator drift. The remainder of the neurologic examination is normal. CT scan of the head without contrast shows no hemorrhage or evidence of acute ischemic infarction. CT angiography of the head and neck does not demonstrate a large vessel occlusion. ECG shows sinus rhythm. Which of the following is the best next step in management of this patient?

Question

A 62-year-old man comes to the emergency department for evaluation of weakness.  Five hours ago, he experienced abrupt-onset weakness in his left arm and leg.  The symptoms improved over the next 30 minutes and he had no associated blurry vision, slurred speech, or facial drooping.  However, the patient states he is still not "back to normal."  He has never experienced similar symptoms.  Medical history is significant for hypertension, hyperlipidemia, and osteoarthritis.  The patient takes no medications.  He has a 25-pack-year history but quit smoking 5 years ago.  Blood pressure is 160/96 mm Hg and pulse is 69/min and regular.  There are no carotid bruits.  Neurologic examination shows mild, left-sided pronator drift.  The remainder of the neurologic examination is normal.  CT scan of the head without contrast shows no hemorrhage or evidence of acute ischemic infarction.  CT angiography of the head and neck does not demonstrate a large vessel occlusion.  ECG shows sinus rhythm.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d166_e107_bc81_139b072970ed_MD0003_00 This patient's acute onset of left-sided weakness with persistent pronator drift is concerning for a stroke. To differentiate between ischemic and hemorrhagic stroke, a noncontrast CT scan of the head is performed. The absence of hemorrhage on this patient's CT suggests an ischemic stroke. The preferred initial therapy for ischemic stroke is systemic thrombolytic therapy (eg, intravenous tissue plasminogen activator), which is administered to patients without contraindications who present within 4.5 hours of symptom onset. However, this patient's symptoms began 5 hours ago, so he is outside the window of eligibility for thrombolysis (Choice E). In addition, this patient is not a candidate for mechanical thrombectomy because there is no large vessel occlusion on CT angiography. contraindications When ischemic stroke patients (such as this one) are ineligible for reperfusion therapy with thrombolysis and/or mechanical thrombectomy, they should immediately receive antiplatelet therapy (eg, aspirin, clopidogrel). This reduces the risk of early recurrence of ischemic stroke and is therefore given even before the full workup (eg, ECG, carotid duplex ultrasonography) for a stroke source is complete. In contrast, if either thrombolysis or mechanical thrombectomy is performed, antiplatelet therapy is typically withheld for 24 hours to decrease the risk of bleeding (eg, hemorrhagic conversion). (Choices B and C) Parenteral anticoagulation (eg, intravenous heparin) should not be used in the acute management of ischemic stroke (even if due to atrial fibrillation [AF]) because it increases the risk of hemorrhagic conversion. Oral anticoagulation (eg, rivaroxaban, apixaban, warfarin) is often used for long-term stroke prevention when stroke is caused by a cardioembolic event. However, this patient's regular pulse and normal ECG do not suggest a cardioembolic source (eg, AF). Antiplatelet therapy should be initiated now, after which further workup to exclude cardioembolism (eg, ECG, telemetry) can be performed. (Choice D) Reversible, titratable antihypertensive agents (eg, nicardipine, labetalol) are often used to control blood pressure in ischemic stroke patients who are candidates for thrombolysis. In contrast, for patients who do not receive thrombolysis, permissive hypertension is recommended to maintain cerebral perfusion, especially to the ischemic penumbra (ie, hypoperfused brain at risk for infarction). control blood pressure Educational objective: Patients with ischemic stroke who are not eligible for thrombolytic therapy or mechanical thrombectomy should receive antiplatelet agents (eg, aspirin, clopidogrel) to decrease the risk of early recurrent ischemic stroke. References: Acute ischemic stroke: management approach. (http://www.ncbi.nlm.nih.gov/pubmed/31485123) Dual versus mono antiplatelet therapy for acute non-cardio embolic ischemic stroke or transient ischemic attack, an efficacy and safety analysis-updated meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/32493229) Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24030500)

A 62-Year-Old Man Comes to the Emergency Department for Evaluation